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Adult PTSD and Its Treatment With EMDR: A Review

of Controversies, Evidence, and Theoretical Knowledge

Sarah Schubert
Christopher W. Lee
Murdoch University, Western Australia

This article provides an overview of selective issues relating to adult posttraumatic stress disorder (PTSD)
and its treatment with eye movement desensitization and reprocessing (EMDR). The article begins by
providing a historical overview of PTSD, and debates about the etiology and definition of PTSD are dis-
cussed. The most predominant theories of PTSD are summarized by highlighting how they have evolved
from traditional behavioral accounts based on the assumption that PTSD is an anxiety disorder to theo-
ries that now incorporate information-processing models. This article then examines the development of
EMDR and the corresponding body of research that clearly demonstrates its efficacy for the treatment for
adult PTSD. The underlying mechanisms of EMDR are discussed, with a focus on the importance of the
eye movement component and how the therapeutic processes in EMDR differ from those of traditional
exposure therapy. Finally, the adaptive information-processing (AIP) model that underlies EMDR is out-
lined, and evidence for the model is summarized. The article concludes by suggesting future research
based on questions raised about PTSD and its treatment with EMDR when the AIP model is compared to
other information-based theories of PTSD.

Keywords: EMDR; PTSD; review; theory; mechanisms of action

Brief Extract

The Role of Eye Movements in EMDR

Although the clinical efficacy of EMDR has been
demonstrated, the role of the eye movements (EMs)

Journal of EMDR Practice and Research, Volume 3, Number 3, 2009 117

© 2009 EMDR International Association DOI: 10.1891/1933-3196.3.3.117
in EMDR continues to be controversial, with crit- At present, more research is required to examine the
ics arguing that they are superfluous to the method precise causal role of the EMs in EMDR. For example,
(i.e., Nevid, Rathus, & Greene, 2008). Although find- do EMs enhance the processing of memories, leading
ings regarding the role of EMs are inconsistent, it is to physiological dearousal, or do the physiological ef-
important to note that much of the research in this fects of the EMs facilitate the processing of memo-
area is filled with methodological problems, such as ries? For a more thorough review of the role of EMs
analogue studies with small, nonclinical samples and in EMDR, see Propper and Christman (2008) and
insufficient use of EMs. To date, no randomized con- Gunter and Bodner (this issue).
trolled trial has been conducted to compare EMDR
with EMs to EMDR without EMs on a large sample The Effects of EMDR Are Different
of adults with PTSD. Thus, ruling out the need for to Exposure
EMs in EMDR is premature. Furthermore, Perkins
Although some reviewers have suggested that the
and Rouanzoin (2002) highlight that
main effect in EMDR is that akin to traditional expo-
EMDR has received empirical validation as a sure (i.e., Benish, Imel, & Wampold, 2008), there are
treatment for PTSD, and the tested procedure three major differences between the therapeutic pro-
includes the eye movement (or alternative dual- cesses that distinguish EMDR from traditional expo-
attention) component. Therefore, the removal sure. According to a strict exposure definition, these
of these stimuli from the validated procedure differences should result in EMDR being ineffective
requires prior component analyses adequate to for treating PTSD as the procedures should sensitize
rule them out as a significant treatment element. rather than desensitize its recipients (Perkins & Rouan-
In the absence of such studies, their removal is zoin, 2002). First, EMDR is not based on habituation,
without empirical justification. (p. 86) as it uses short 20- to 50-second, interrupted exposures
rather than continuous 20- to 100-minute exposures,
Although the exact role of the EMs in EMDR remains
traditionally recommended for prolonged exposure
unknown, numerous laboratory studies have exam-
(Rogers & Silver, 2002). Second, EMDR is nondirec-
ined the effects of EMs on memory and cognitive
tive, allowing for free association. The client often
processes for participants not experiencing PTSD.
moves quickly through scenes or skips scenes by spon-
Research suggests that EMs may contribute to the ef-
taneously changing to other memories that arise. In
fectiveness of EMDR through a number of different
EMDR, this is not seen as avoidance but is instead
processes, as they have been found to decrease the
viewed as effective memory processing (Lee & Drum-
vividness and/or emotionality of autobiographical
mond, 2008; Lee, Taylor, & Drummond, 2006). Third,
memories (Andrade, Kavanagh, & Baddeley, 1997;
in EMDR, reliving the traumatic memory in the pres-
Barrowcliff, Gray, Freeman, & MacCulloch, 2004;
ent tense is not a requirement of therapy. Taking a
Kavanagh, Freese, Andrade, & May, 2001; Maxfield,
third-party perspective on the trauma is also not seen
Melnyk, & Hayman, 2008; Sharpley, Montgomery,
as avoidance, and, unlike traditional exposure, reliving
& Scalzo, 1996; van den Hout, Muris, Salemink, &
is not associated with improvement in EMDR (Lee &
Kindt, 2001), enhance the retrieval of episodic memo-
Drummond, 2008). According to the assumptions of
ries (Christman, Garvey, Propper, & Phaneuf, 2003),
emotional processing theory (Foa & Rothbaum, 1998),
and increase cognitive flexibility (Kuiken, Bears,
which underlie exposure therapy for PTSD, the type
Miall, & Smith, 2001–2002) and may change inter-
of exposure that occurs in EMDR should result in min-
hemispheric coherence in frontal areas of the brain
imal decreased fear if exposure is the proposed mecha-
(Propper, Pierce, Geisler, Christman, & Bellorado,
nism of change. Yet EMDR is effective in treating adult
2007). Research has also demonstrated that EMs pro-
PTSD and associated symptoms.
duce psychophysiological dearousal when accessing
distressing memories (i.e., Barrowcliff et al., 2004).
Theories Regarding the Underlying
Additional treatment studies that have demonstrated
Mechanisms of EMDR
a dearousal effect measured physiological changes
during EMDR and indicate that the EMs are associ- Common factors across psychotherapies contribute to
ated with physiological responses that are characteris- their individual efficacy. However, it does not follow
tic of an orienting response (Sack, Lempa, Steinmetz, that all improvement is due mainly to those factors.
Lamprecht, & Hofmann, 2008) but may also resem- EMDR involves many therapeutic elements. There-
ble physiological characteristics of REM sleep (Elof- fore, a number of agents of change may be involved
sson, von Sche’ele, Theorell, & Söndergaard, 2008). beyond the effects of exposure and the EMs. Yet, like

Journal of EMDR Practice and Research, Volume 3, Number 3, 2009 125

EMDR Treatment of Adult PTSD
any therapy, the exact mechanisms of change under- memory and a concurrent task, such as EMs. Evidence
lying EMDR are currently unknown, but a number for these proposed mechanisms of action have come
of theories exist. EMDR is currently guided by the out of various research paradigms that have examined
AIP model, which is consistent with Foa and Kozak’s how EMDR may work.
(1986) information-processing theory. There are, how-
ever, four other main hypotheses regarding the theo-
Research Examining the AIP Model
retical mechanisms of EMDR that have, in the current
third wave of research, begun to accumulate a sound Research into the activation of an orienting response
empirical base and offer support for the AIP model: (MacCulloch & Feldman, 1996) in EMDR provides
orienting response activation, REM-like mechanisms, support that a relaxation response occurs when the
the theory of increased hemispheric communication, EMs begin that may facilitate treatment by reducing
and working memory accounts. stress to a tolerable level so that processing of memo-
ries can occur (Barrowcliff et al., 2004; Elofsson et al.,
2008; Sack et al., 2008). Research that has investigated
AIP Model
physiological responses created by the EMs in EMDR
The AIP model offers an explanation for the basis and has also noted that changes characteristic of a REM-
recovery of trauma symptoms, it guides clinical case like state occur (Elofsson et al., 2008). Stickgold (2002)
conceptualization, and directs treatment. The AIP has proposed a REM hypothesis of EMDR that states
model, which is consistent with other learning-based that the EMs in EMDR, through repeated orienting
theories of PTSD, proposes that new experiences are responses, may “push-start” memory processing in
processed by assimilating them with existing memory the brain by inducing a physiological and neurological
networks and that adaptive learning takes place (Sha- state that is akin to REM sleep that aids in the trans-
piro, 1995, 2001). Shapiro (2001) states that adaptive fer and integration of memories. Overall, the EMs in
learning occurs when information from new experi- EMDR have an effect on physiology by creating either
ences are perceived and “the connections to appropri- an orienting response or a REM-like state, but further
ate associations are made and that the experience is research is required to clarify the effect and refine re-
used constructively by the individual and is integrated lated theories.
into a positive emotional and cognitive schema” Research into the theory of increased hemispheric
(p. 30). According to the AIP model, pathology arises communication provides empirical support for Sha-
when memories of an experience are not adequately piro’s (2001) second hypothesized mechanism that
processed. Rather, the memory is dysfunctionally information processing in the treatment of traumatic
stored in its own neural network, which, like a fear memories is facilitated by neurological changes in the
network (Foa & Kozak, 1986), contains thoughts, im- brain that activate and strengthen weak associations.
ages, emotions, and sensations associated with the The theory of increased hemispheric communication
event that, when triggered, influence perceptions, proposed that horizontal EMs increase communica-
attitudes, and behavior in the present. Whether the tion between both hemispheres of the brain, thus en-
memories are of an event that meets criterion A(1) hancing one’s ability to remember the traumatic event
for PTSD or are memories of “small t” traumas or while not becoming aroused (Christman et al., 2003).
whether the predominant emotions are criterion A(2) However, at present, mixed findings characterize the
emotions or other emotions such as shame or guilt is evidence for the increased hemispheric communica-
irrelevant to the model. The main etiological factor tion account of how EMDR works. For example, re-
of trauma symptoms is that the memories are uninte- cent research by Propper et al. (2007) reported that
grated and dysfunctionally stored. engaging in bilateral EMs decreased rather than in-
The AIP model suggests that it is the activation creased interhemispheric coherence. Also contrary to
of the information-processing system that leads to the account, Gunter and Bodner (2008) demonstrated
the resolution of dysfunctionally stored traumatic that vertical EMs, which in theory do not increase
memories. However, Shapiro (2001) proposes that in- hemispheric communication, were equally effective
formation processing is facilitated primarily by three as horizontal EMs at reducing ratings vividness, emo-
mechanisms in EMDR: (a) deconditioning that pro- tionality, and completeness of unpleasant autobio-
ceeds through a relaxation response, (b) neurologi- graphical memories.
cal changes in the brain that activate and strengthen Research has also begun to accumulate to support
weak associations, and (c) factors that are involved Shapiro’s (2001) third hypothesis, that the client’s dual
with the client’s dual focus of attention on both the focus of attention on both the trauma memory and a

126 Journal of EMDR Practice and Research, Volume 3, Number 3, 2009

Schubert and Lee
concurrent task is a mechanism that facilitates informa- processed. There are, however, some distinct differ-
tion processing in EMDR. What is gaining empirical ences between AIP and current information-based
support are working memory models that can account theories of PTSD, and these differences have impor-
for the discrepant findings within research that have tant implications for theory and treatment of PTSD.
examined the increased hemispheric communication
account. For example, Gunter and Bodner (2008) ex-
AIP Contrasted With Other
plained the equivalent benefits for vertical and hori-
Psychological Models of PTSD
zontal EMs by proposing that their finding supported
a working memory account, as both tasks taxed the Unlike AIP, dual-representation theory (Brewin et al.,
visual spatial sketch pad component of working mem- 1996) assumes that the concept of a single memory
ory to a similar degree. A working memory account system is inadequate to account for the full range of
of EMDR proposes that the dual-attention stimuli in complex phenomena associated with PTSD. Thus,
EMDR, whether it be EMs or some other task such as previously mentioned, two memory systems
as tapping or tones, leads clients to attend to both the are proposed to exist: conscious VAMs and uncon-
external stimulus and internally to the trauma-related scious SAMs, which are unintegrated and triggered
memories (Maxfield et al., 2008). Baddeley’s (1986) by reminders of the trauma and, when triggered,
model of working memory suggests that each compo- are accompanied by emotional and/or physiologi-
nent of working memory has limited memory resource cal arousal experienced during the trauma. Although
capacity, so when two tasks make demands on the at- dual-representation theory is not linked to any spe-
tentional capacity of a component, performance on the cific treatment protocol, like AIP is linked to EMDR,
primary task deteriorates. That is, in EMDR, when in- it is proposed that treatment needs to focus on two
dividuals engage in EMs while simultaneously focusing pathological processes. One involves resolving con-
on a memory image, the quality of the image deterio- scious negative beliefs and associated emotions, and
rates, presumably because it gets pushed out of work- the other involves managing intrusive, unintegrated
ing memory and integrated into long-term memory, memories in the SAM system (Brewin & Holmes,
where the memory then becomes less vivid and less 2003). It is hypothesized that following effective
emotional. Space does not permit an extended discus- exposure and/or cognitive therapy, the old SAMs
sion on the research that has examined working mem- remain intact but are no longer triggered and expe-
ory effects; for this and for more in-depth discussions rienced because newly created VAMs become more
of the orienting response, REM-like mechanisms, and distinctive and rehearsed and thus have a retrieval
the increased hemispheric communication account of advantage when the memory is triggered. In contrast
EMDR, refer to Gunter and Bodner (this issue). to the assumptions in AIP, it is also proposed that be-
Consistent with other information-processing the- cause the old SAMs remain unchanged and are not
ories of PTSD, AIP theory assumes the existence of an integrated in memory in any way, they retain their
information-processing system that, when working potential to be retrieved by the right combination of
appropriately, incorporates new experiences into pre- triggers (Brewin & Holmes, 2003). Also in contrast to
existing memory networks, which are the basis of per- AIP, where it is assumed that processing new infor-
ception, attitudes, and behavior. At the heart of AIP mation in the therapeutic process aids in the assimi-
and other information-processing models of PTSD, lation of the trauma memory into existing memory
such as emotional processing theory (Foa & Roth- networks, it is assumed in dual-representation theory
baum, 1998) and dual-representation theory (Brewin that the new information creates new memories that
et al., 1996), is that recovery of PTSD is all about the compete with the old trauma memories. This sug-
elaboration or processing of memory. The AIP model gests an extinction mechanism over assimilation or
is consistent with emotional processing theory, as it is reconsolidation of trauma memories.
assumed that the fear memory of the traumatic event The precise mechanism by which memories are
needs to be activated and that corrective information processed in the treatment of PTSD remains to be
must be provided that is incompatible with the fear empirically clarified. The AIP model proposes that
structure. Associations are made with existing mem- the mechanism of action in EMDR is “the assimila-
ory networks, resulting in learning, relief of emotional tion of adaptive information found in other mem-
distress, and material becoming available for future ory networks linking into the network holding the
use. All information-processing models assume that previously isolated disturbing event” (Solomon &
dysfunctional trauma reactions result when informa- Shapiro, 2008, p. 316). Thus, EMDR transmutes the
tion relating to a traumatic event is not adequately dysfunctionally stored memory by integrating it with

Journal of EMDR Practice and Research, Volume 3, Number 3, 2009 127

EMDR Treatment of Adult PTSD
preexisting memory networks. Other psychologi- PTSD, and the validity of the diagnostic criteria con-
cal theories propose that treatment of memories in tinues to be challenged. Despite this and the theo-
PTSD is based on extinction, whereby the process is retical advances that have occurred as our knowledge
believed to be that new memories are created that about PTSD has improved, procedures for the two
compete for and attain retrieval advantage over old most effective treatments for PTSD have changed
trauma memories (Suzuki et al., 2004). Thus, origi- minimally across time. Exposure procedures have
nal trauma memories are able to be retrieved in their changed very little over the years, and the EMDR
original form if triggered by the right combination of protocol has remained unchanged since 1991 (Sha-
cues in the future (Brewin & Holmes, 2003). Solomon piro, 1991). Since Shapiro’s (1989) seminal publication
and Shapiro (2008) suggest that research comparing that demonstrated the effectiveness of EMDR, what
recall of original memories and rates and kinds of re- is now known after 20 years of research is that EMDR
trieval patterns can shed light on whether the primary is an efficacious treatment for adult PTSD. What is
mechanism of action is based on extinction or on as- also known is that the EMs in EMDR appear to pro-
sociation, assimilation, and reconsolidation. They duce various effects that facilitate memory processing
also suggest that EMDR, because of the process of and that the processes involved in EMDR are differ-
assimilation, may aid in lowered relapse rates when ent from those of traditional exposure. However,
clients experience a similar trauma in the future. although evidence is accumulating in support of the
Future research needs to compare extinction and AIP model on which EMDR is based, there is still no
reconsolidation models. Solomon and Shapiro sug- empirically supported model that is capable of ex-
gest that this could be done by following individuals plaining the precise underlying mechanism of EMDR.
treated with EMDR and exposure-based treatments One must be reminded, though, that even after years
to investigate if there is a difference in participants’ of research, we are still struggling to determine the
reactions to similar traumas posttreatment. mechanisms through which many psychotherapeutic
Future research could also investigate other differ- treatments operate and create change. In addition,
ences between AIP and emotional processing models the specific mechanisms through which PTSD devel-
of PTSD. For example, the AIP model assumes that ops and resolves are not entirely understood, and, as
trauma symptoms resolve as a result of processing sa- yet, no theory adequately accounts for and explains
lient or associated memories related to the traumatic all the phenomena involved in PTSD. The success of
event. Alternatively, emotional processing theory EMDR has challenged existing contemporary theo-
(Foa & Rothbaum, 1998) assumes that it is necessary ries of PTSD and has advanced our understanding of
to focus on and relive the traumatic event, to maintain the therapeutic processes in PTSD. In turn, current
a level of arousal until habituation occurs. Research theories of PTSD may facilitate our understanding of
supporting the AIP model demonstrates that informa- how EMDR works to resolve PTSD. Comparing and
tion processing through association leads to changes contrasting EMDR and non-EMDR theories of PTSD
such as reductions in vividness and emotionality and has more potential to advance our knowledge of ef-
in appraisals related to the memory. Targeting as- fective treatments.
sociated memories in non-EMDR treatment studies
has also been found to reduce the vividness, distress, Note
and negative beliefs associated with target memories
(Wild, Hackman, & Clark, 2008). EMDR may there- 1. Effect sizes pretreatment to posttreatment and pre-
treatment to follow-up were calculated for the PTSD mea-
fore be particularly well suited for individuals who are
sures used in each study using Cohen’s d statistic. Cohen’s
either avoidant of therapy for fear of having to relive
d is calculated by determining the difference in mean scores
the trauma or cannot tolerate repeated imaginal re- for each condition divided by the pooled variance (i.e., SD-
living of the traumatic event. Future research could pooled = [(SD2 pre + SD2 post)/2]).
focus on clarifying if it is possible to reduce trauma
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